By Susan Dickson
The Orange County Health Department exists to enhance the quality of life, promote the health and preserve the environment for all people in Orange County, and officials say certain provisions of the Patient Protection and Affordable Care Act, affirmed earlier this summer by the Supreme Court, could help facilitate that mission.
Under the act, a vast number of uninsured Americans should obtain health coverage by 2014. In addition, the act places a focus on preventive health care â€“ something Orange County Health Director Colleen Bridger praises.
â€œThatâ€™s kind of the core of public health,â€ she said, â€œhelping people understand the importance of preventive health.â€
â€œItâ€™s nice to have the big guy in the corner when it comes to talking that talk,â€ she added.
The health department provides a number of health care services, including primary care, dental services, maternal health care, immunizations and HIV/AIDS testing and counseling. But beyond medical care, the department also takes an educational role, promoting safe and healthy lifestyles for county residents.
One of the departmentâ€™s primary roles is that of a safety-net provider for those who canâ€™t afford to obtain medical care otherwise â€“ including many uninsured and Medicaid patients. Some have argued that once most Americans become insured in accordance with the PPACA, safety-net providers like the health department wonâ€™t be needed â€“ but Bridger disagrees.
â€œWhen you increase the number of people who have some sort of insurance coverage without increasing the number of people who can provide it, everybody who provides that service is going to be busier than they were before,â€ she said. â€œWith more and more people having a payer source, theyâ€™re going to come seeking medical services more frequently, and so the private practices arenâ€™t going to have enough capacity to serve everybody who needs to be served anyway.â€
In addition, safety-net providers like health departments serve a certain niche of patients, Bridger said, like those who might be late to appointments because they have to use public transportation or those who have mental as well as physical issues they need served.
â€œThey really need a lot more time and attention than can happen in a private setting,â€ she said.
The Medicaid question
Exactly how many uninsured health department patients will gain coverage under the PPACA is somewhat unclear, with the federal penalties for states opting out of the actâ€™s expansion of Medicaid â€“ the joint state-federal insurance program for low-income Americans â€“ struck down in the Supreme Court decision.
North Carolina lawmakers have not yet indicated whether or not the state will participate in the actâ€™s Medicaid expansion provision, which would expand Medicaid eligibility to include anyone making less than 133 percent of the federal poverty level. For safety-net providers like the Orange County Health Department, that decision will seriously affect their budgets.
â€œWe are of course very interested in what is going to happen with that decision,â€ Bridger said. â€œThereâ€™s really nothing we can do other than just keep watching. The interesting thing about health care for the last 10 to 15 years is that if youâ€™re not changing, youâ€™re not doing it right, so being able to turn on a dime is less of a big deal for us now than it was 10 years ago.â€
At this point, Bridger said the department will simply proceed with the assumption that Medicaid funding wonâ€™t be lower than current levels.
â€œItâ€™s always easier to operate from that assumption,â€ she said.
Should North Carolina choose to participate in the Medicaid expansion, that could free up some much-needed dollars for the health department, according to Corey Davis, a member of the Orange County Board of Health and a public health attorney with the National Health Law Program.
â€œEvery dollar that safety-net hospitals, that community health centers, that health departments arenâ€™t paying for care out of their budgets, things that theyâ€™re already providing out of state dollars, out of local dollars â€¦ that frees up funds for other things,â€ he said.
â€œThe more federal dollars that come into public health departments for medical activities mean that we are likely to be able to provide more and more-comprehensive medical activities,â€ Davis continued. â€œThat means looking at things like community gardens, like walking paths. It could mean stepped-up surveillance activities â€¦ to more quickly recognize and address things like a whooping cough outbreak.â€
In addition, Davis said the Medicaid expansion could enable the health department to spend more dollars taking on community-wide issues like obesity.
â€œItâ€™s exactly the kind of problem that is difficult to solve without a commitment at the county or state level. Itâ€™s exactly the kind of thing that health departments should be doing,â€ he said.
However, especially during tight budget years, health department dollars are stretched and â€œthere is no extra money,â€ Davis said, and â€œif we have that $1,000 and we have kids with whooping cough, weâ€™re going to treat the kids with whooping cough.â€
Regardless of the Medicaid expansion, Bridger said she does worry that some politicians want to overturn the entire bill.
â€œThat is certainly on our minds,â€ she said, â€œand it would be unfortunate for access to care.â€